Provider Demographics
NPI:1780225532
Name:GONZALES, FUMIKO IRENE FUKUMOTO (RADT)
Entity type:Individual
Prefix:
First Name:FUMIKO
Middle Name:IRENE FUKUMOTO
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SARATOGA AVE UNIT 609
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6406
Mailing Address - Country:US
Mailing Address - Phone:424-404-2437
Mailing Address - Fax:
Practice Address - Street 1:5318 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1810
Practice Address - Country:US
Practice Address - Phone:323-293-6291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)